​Active Implementation

ACTIVE IMPLEMENTATION FRAMEWORKS FOR PROGRAM SUCCESS
Adopted from:  National Implementation Research Network at the Frank Porter Graham Child Development Institute:  Chapel Hill, North Carolina

The research to practice gap is a critical issue because children and families cannot benefit from services they don’t receive.  In 2005, the National Implementation Research Network released a monograph (Fixsen, Naoom, Blase, Friedman, & Wallace) that synthesized implementation research findings across a range of fields and developed four overarching frameworks, referred to as the Active Implementation Frameworks, based on these findings.

​Active Implementation Frameworks

I. Implementation Stages - Conducting stage-appropriate implementation activities is necessary for successful service and systems change.
II. Implementation Drivers - Developing core implementation components, referred to as Implementation Drivers, results in an implementation infrastructure that supports competent and sustainable service delivery.
III. Organized, Expert Implementation Support - Implementation support can be provided externally through active purveyors and intermediary organizations or internally through Implementation Teams.  There is evidence that creating Implementation Teams that actively work to implement interventions results in quicker, higher-quality implementation.
IV. Policy-Practice Feedback Loops - Connecting policy to practice is a key aspect of reducing systems barriers to high-fidelity practice.

​I. Stages of Implementation

Exploration Stage
The overall goal of the exploration stage is to examine the degree to which a particular model, program, or approach meets the community’s needs and whether implementation is feasible. In this first stage of implementation, communities must assess the goodness of fit between potential program models and the needs of the children and families they serve. Requirements for implementation must be carefully assessed and potential barriers to implementation examined. Involvement of key stakeholders and the development of program champions are key activities during this stage. A prerequisite for implementation is to ensure that core intervention components are identified and fully operationalized. Even with existing evidence-based and evidence-informed practices, more program development work might need to be done during the exploration stage before final implementation decisions can be made.

Installation Stage
The installation stage is often overlooked in implementation. Once a decision is made to adopt a program model, many structural and instrumental changes in a number of settings and systems must be made in order to initiate the new practices. Practical efforts to initiate the new program are central to the installation stage and include activities such as developing referral pathways, ensuring that financial and human resources are in place, and finding physical space or purchasing equipment and technology. Developing the competence of practitioners is a key component of this stage to ensure that programs are implemented with fidelity.

Initial Implementation
During the initial implementation stage, the new program model or initiative is put into practice.  Attempts to implement a new program or innovation often end or seriously falter during the installation stage or early in the initial implementation stage.  The key activities of the initial implementation stage involve strategies to promote continuous improvement and rapid cycle problem solving.  Using data to assess implementation, identify solutions, and drive decision making is a hallmark of this stage.  It is critical to address barriers and develop system solutions quickly rather than allowing problems to re-emerge and reoccur.

Full Implementation
Full implementation occurs as the new learning at all levels becomes integrated into practice, organization, and system settings and practitioners skillfully provide new services. The processes and procedures to support the new way of work are in place, and the system, although never completely stable, has largely been recalibrated to accommodate and, it can be hoped, fully support the new ways of work. The time it takes to move from initial implementation to full implementation will vary depending upon the complexity of the new program model, the baseline infrastructure, the availability of implementation supports and resources, and other contextual factors.

Sustainability
Sustainability planning and activities need to be an active component from the initial stages of implementation. To sustain an initiative, both financial and programmatic sustainability are required. Financial sustainability involves ensuring that the funding streams for the new practice are established, reliable, and adequate. Programmatic sustainability is related to ensuring that sustainable supports are in place to continue effective training, coaching, and performance assessment protocols; to measure fidelity and make data-driven decisions for continuous improvement; and to ensure that facilitative policy-making and procedural decisions continue to support full implementation.

​II. Implementation Drivers

The implementation drivers are the core components or building blocks of the infrastructure needed to support practice, organizational, and systems change. There are three types of implementation drivers and when used collectively, these drivers ensure high-fidelity and sustainable program implementation: competency drivers, organization drivers, and leadership drivers.
I. Competency Drivers
Competency drivers are mechanisms to develop, improve, and sustain practitioners’ and supervisors’ ability to implement a program or innovation to benefit children and families.

  1. Selection – Effective staffing requires the specification of required skills, abilities, and other model-specific prerequisite characteristics.
  2. Training—Trainers need to learn when,  how, and with whom to use new skills and practices. Training should provide knowledge related to the theory and underlying values of the program, use adult learning theory, introduce the components and rationales of key practices, provide opportunities to practice new skills to meet fidelity criteria, and receive feedback in a safe and supportive training environment.
  3. Coaching—Most new skills can be introduced in training but must be practiced and mastered on the job with the help of a coach. Districts  should develop and implement service delivery plans for coaching that stipulate where, when, with whom, and why coaching will occur; use multiple sources of data to provide feedback to practitioners including direct observation; and use coaching data to improve practice and organizational fidelity.
  4. Performance Assessment—Evaluation of staff performance is designed to assess the application and outcomes of skills that are reflected in selection criteria, taught in training, and reinforced in coaching. Districts  should develop and implement transparent staff performance assessments, use multiple sources of data to assess performance, institute positive recognition so assessments are seen as an opportunity to improve performance, and use performance assessment data to improve practice and organizational fidelity.

II. Organization Drivers
Organization drivers intentionally develop the organizational supports and systems interventions needed to create a hospitable environment for new programs and innovations by ensuring that the competency drivers are accessible and effective and that data are used for continuous improvement.

  1. Decision-Support Data Systems— Data are used to assess key aspects of overall performance of an organization and support decision making to ensure continuing implementation of the intervention over time. Decision-support data systems include quality assurance data, fidelity data, and outcome data. Data need to be reliable, reported frequently, built into practice routines, accessible at actionable levels, and used to make decisions.
  2. Facilitative Administration— Administrators provide leadership and make use of a wide range of data to inform decision making, support the overall processes, and keep staff organized and focused on the desired innovation outcomes. Districts  should ensure leadership is committed and is available to address challenges and create solutions, develop clear communication protocols and feedback loops, adjust and develop policies and procedures to support the new way of work, and reduce administrative barriers.
  3. Systems Interventions—These are strategies to work with external systems to ensure the availability of financial, organizational, and human resources required to support the work of practitioners. The alignment of external systems to support the work is a critical aspect of implementation.

III. Leadership Team Drivers
The use of the Leadership Driver in the context of active implementation focuses on leadership approaches related to transforming systems and creating change.

  1. Technical challenges are those characterized by pretty clear agreement on a definition of the dimensions of the problem at hand.  We can be reasonably certain that given the agreed upon problem and the dimension of the problem, if we engage in a relevant set of activities we will arrive at a solution – not necessarily quickly or easily but the challenge and path to a solution are largely known. Technical challenges can be managed. The leader can form a team, make a plan, make decisions, hold people accountable and execute the solution
  2. Adaptive challenges are characterized by the definition of the problem being much less clear, and the perspectives on the “issue” at hand differ among stakeholders.  Viable solutions and implementation pathways are unclear and defining a pathway for the solution requires learning by all. This “all” means that the primary locus of responsibility is not a single entity or person. These types of challenges require a different type of leadership and often require leadership at many levels
    • Getting on the balcony - Stepping out of the fray to see the key patterns and the bigger picture. Leaders also need  to recognize the patterns of work avoidance and the potential for conflict.
    • Identifying the adaptive challenge - Putting the unspoken issues out on the table. It also involves recognizing the  challenges to and uncomfortable changes that may be required in values, practices and relationships.
    • Regulating distress - Creating a safe environment for challenges to be discussed, and creating a space for diversity of  opinion, experiences, and values as well as the opportunity to challenge assumptions. Stress is accepted, tolerated, and  regulated by the leader.
    • Maintaining disciplined attention - Being aware of patterns of behavior that indicate that there is a purposeful or  unconscious attempt to avoid disturbing or difficult issues. These patterns and behaviors can show up as scapegoating  or blaming others; denying that the problem exists or is truly problematic; or diverting attention by focusing on  technical issues.
    • Giving the work world back - Creating conditions that help people take greater responsibility for the work of change,  including defining and solving the problems. The leader supports staff rather than directing or controlling them. Giving  the work back to the people also requires instilling and expressing confidence in others so that they will take risks, and  backing them up when they make mistakes.
    • Protecting all voices - Relying on others to raise questions about adaptive challenges and provide support and protection for employees who identify internal conflicts in the organization. This includes providing a legitimate space  for those who constructively disagree.

​III. Implementation Teams

Traditional approaches to disseminating and implementing evidence-based and evidence-informed practices for children and families have not been successful in closing the research-to-practice gap. In extensive reviews of the dissemination and diffusion literature (Greenhalgh, Robert, MacFarlane, Bate, & Kyriakidou, 2004; Hall & Hord, 2011), past efforts to support implementation have been characterized as “letting it happen” or “helping it happen”(Greenhalgh et al.,p. 593). Approaches that let implementation happen leave it to agency administrators, practitioners, and policymakers to make use of research findings on their own. Approaches that help it happen provide manuals or Web sites to help implementation happen in real world settings. Both of these approaches have been found to be insufficient for promoting the full and effective use of innovations (Balas & Boren, 2000; Clancy,2006). Greenhalgh et al.(2004) identified a new category they called “making it happen,” (p. 593) in which expert implementation teams can play a role in using evidence-based strategies to actively support implementation of a new innovation or initiative.

Implementation teams provide an internal support structure to move selected programs and practices through the stages of implementation in systemic change. The teams focus on:

  1. Increasing “buy-in” and readiness
  2. Installing and sustaining the implementation infrastructure
  3. Assessing fidelity and outcomes
  4. Building linkages with external systems
  5. Problem-solving and sustainability

An advantage of relying on implementation teams is that the team collectively has the knowledge, skills, abilities, and time to succeed. Collectively, the core competencies of the implementation team include:  knowledge and understanding of the selected intervention and its linkages to outcomes; knowledge of implementation science and best practices for implementation; and applied experience in using data for program improvement.

Implementation teams might actively work with external experts of evidence-based practices and programs in PBIS. PBIS experts represent a group of individuals very knowledgeable about the innovation who actively work to help others implement the new innovation with fidelity and good effect. PBIS experts are often affiliated with researchers and training and technical assistance centers.

​IV. Improvement Cycles:  Policy-Practice Feedback Loops

Connecting policy to practice is a key aspect of reducing early childhood systems barriers to high-fidelity implementation.  There must be good policy to enable good practice, but practice must also inform policy.  Many times early childhood practitioners experience barriers to service delivery that can be solved only at the policy level. There needs to be a system in place that ensures practice experiences are being fed back to the policy level to inform decision making and continuous improvement.

Policy–practice feedback loops are one type of improvement cycle and, therefore, follow the Plan, Do, Study, Act cycle (Deming, 1986; Shewhart, 1931) that signifies all improvement cycles.

  • Plan - Specify the plan that helps move service and interventions forward
  • Do - Focus on facilitating the implementation of the plan
  • Study - Develop assessment to understand how the plan is working
  • Act - Make changes to the next iteration of the plan to improve implementation

Policy-practice feedback loops demonstrate the Plan, Do, Study, Act cycle on a larger scale where moving through the cycle takes longer than when the Plan, Do, Study Act is happening at one level of the system.

Effective policy-practice feedback loops must be institutionalized into the agency’s way of work to ensure that change happens on purpose.  New practices do not fare well in existing organizational structures and systems.  Too often, effective interventions are changed to fit the system, as opposed to the existing system changing to support the effective interventions.  Embedded policy-practice feedback loops promote system change to support service change.